Student Registration Form

Student Registration Form

Fill out the form carefully for registration
Student Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
I'm interested in enrolling my child in
Mother's Name

First NameLast Name
Mother's Email
example@example.com
Mother's Phone Number
Mother's Occupation
Mother's Work Phone Number
Father's Name

First NameLast Name
Father's Email
example@example.com
Father's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Father's Occupation
Father's Work Phone Number
Emergency Contact /Alternate Pick up Person

First NameLast Name
Emergency / Alternate Pick up Person Phone Number
Format: (000) 000-0000.
Child's Physician
Name and number
Please list any allergies or food considerations for your child.
Please list any medical considerations your child may have.
Describe some of your child's interests and favorite activities
Anything else I should know about your child?
How did you hear about our preschool?
What are you hoping your child gains from preschool?
I understand and agree that
Signature
I would like to Pay my $50 registration fee with:
Should be Empty: